Recognise, Investigate and Refer
Mental health problems present in a variety of ways and should be considered as part of a routine medical history.
A mental health problem should be considered if any of the following signs are observed by medical staff, team coaching and management, team mates or family members:
- Drop in functioning – Performing under par with no physical explanation
- Withdrawn - Social withdrawal and loss of interest in others
- Apathy - Loss of initiative or desire to participate in any activity
- Unusual behaviour - Odd, uncharacteristic, peculiar behaviour
- Reports from team mates that ‘something is wrong’
- Injury symptom exaggeration or over-protection
- Appetite or weight changes (eating much more or much less) and / or poor self-care
- Overuse of alcohol, drugs, pain medication
- Slower recovery from injury with no physical explanation
If a player reports any of the following symptoms a mental health problem should also be considered as part of the differential diagnosis:
- Sleep disturbance - too much or too little
- Problems with concentration or memory
- Mood changes - rapid or dramatic shifts in feelings and / or uncharacteristic emotional outbursts
- Feeling hopeless, worthless, guilty or down much of the time
- Nervousness - Fear or suspiciousness of others or a strong nervous feeling
- Increased sensitivity generally - heightened sensitivity to sights, sounds, smells or touch
- Expressing illogical / unusual thoughts (e.g. having powers, magical thinking)
- Changes in speech tone and delivery
- Feeling disconnected - A vague feeling of being disconnected from oneself or one’s surroundings; a sense of unreality
It is important to undertake a mental health consultation, with the player’s consent, in a private, confidential environment where the player can feel assured that the conversation will not be overheard. You should inform the player that the purpose of the consultation is to talk about their mental health and to help them access support if needed. You must reassure the player that the confidentiality of this consultation is paramount and that information will be securely stored and accessible only to those who have consent to see it.
Remember due to stigma around mental health problems players may find it difficult to talk openly about or trust others with information around their mental health. Creating a trusting, confidential, collaborative environment is key. You should also note that a player is under no obligation to respond to your questions about their mental health and often people present with more than one mental health problem at one time.
As for any medical complaint a history is essential. The following provides a guide for taking a mental health history:
- How have you been doing recently?
- In the past month how would you rate, on a scale from 1-10, where 10 is the highest, how you have felt about:
- Personal wellbeing
- Life outside of rugby
Specific screening questions and clinical history would include:
- Have you experienced mental health problems now or in the past?
- Have you any history of self-harm or attempted suicide?
- Are you currently self-harming? If yes see * below
- Do you have any thoughts of harming or killing yourself or others – If yes see * below.
- Any recent significant life events such as death of a loved one, rugby or family issues?
- In the past month have you had issues with any of the following:
- Memory or concentration difficulties
- Problems with eating or weight – too much or not enough
- Increased sensitivity to light, sound or touch
- Delayed recovery from injury - taking longer than expected
- Worry or agitation
- Drinking more alcohol, using medications to relax or sleep
- Using pain killers or abusing other substances
- Gambling more than usual
- Have any of your team mates commented that your behaviour is unusual?
- Feeling less sociable than usual
- Feeling hopeless, worthless or guilty much of the time
- Low or higher than usual mood or mood changes
- Illogical or unusual thoughts (e.g. superpowers, magical thought)
- Seeing, hearing or smelling things that others would say were not there.
If the player answers yes to any of the above a mental health problem should be considered and if indicated referral to a mental health professional offered.
A list of screening tools is also listed as an appendix to this module. These tools can support you to explore further with the player the nature and extent of any potential mental health problem.
If making a referral to a Mental Health Professional:
- The player must consent to this referral
- You should support the player to access the mental health professional
- Provide a written referral summarising your clinical findings
- Confirm a follow up contact or appointment
Who to refer
The level of intervention required for a player will typically depend on the nature and severity of the player’s symptoms. Low intensity interventions such as psychoeducation and guided self-help are provided for mild mental health problems (e.g. mild or subthreshold depression with no suicidal ideation). More intensive interventions such as cognitive behavioural therapy and /or medication are used in mild to moderate cases with inpatient psychiatric care for the most severe mental health cases.
A clinical psychologist or psychiatrist is often best placed to conduct an initial mental health screening or assessment and to provide direction as to next steps. Your Union, club or players association may have an identified mental health referral network for players experiencing mental health problems.
In addition to rugby-linked services players can also access:
- Public health mental health services (inpatient and outpatient)
- Private mental health services (inpatient and outpatient)
- Services available via health insurance organisations
The National Institute of Clinical Excellence provides evidence-based guidelines on the assessment and treatment of mental health problems should you require further information to guide your referral - nice.org.uk/guidance/conditions-and-diseases/mental-health-and-behavioural-conditions
*Risk to Self or Other
If the player reports current thoughts of harming or killing themselves or another it is crucial to assess whether there is immediate danger and call emergency services if so.
In the case of thoughts around suicide you should ask:
- How frequent and strong are these thoughts and for how long have you had them?
- Do you have a plan around how you will kill yourself? If yes, obtain details of the plan. For example when, where, how, and whether they have the ability to complete the plan.
- Have you been taking drugs or using excessive alcohol?
- Have you tried to hurt or kill yourself before?
- Have you told anyone about how you are feeling?
- Have you had any significant changes in your employment, social life, or family?
- Have you previously received treatment for mental health problems or are you taking any medication?
If the player reports low or infrequent thoughts of suicide with no plan:
- Ask the player what supports are available to them (e.g. close family, friends) and work with the player to create a plan to keep them safe over the coming days (e.g. being around supportive people, calling emergency numbers if feeling suicidal, making an appointment with a mental health professional).
- Ensure to follow up with the player or to have a mental health professional follow up with the player.
- Following the consultation make sure to debrief and get your own support as required.
If you are unsure about how to support a player who is having thoughts of suicide - Call emergency services, your national suicide helpline or a psychiatry colleague for advice and support.
Be aware that those at the highest risk for acting on thoughts of suicide, in the near future, are those who have:
- A specific suicide plan
- The means to carry out the plan
- A set time for this plan and
- The intention to carry out the plan
If a player reports strong or frequent thoughts about suicide and/or a specific suicide plan immediate help is required for the player from psychiatric or emergency services.
In the case of thoughts around self-harm following the following guidelines: www.nice.org.uk/guidance/cg16/chapter/1-Guidance#the-management-of-self-harm-in-primary-care
If based on the player’s report you are concerned they are in immediate danger of harming another person, immediately contact the police.
If child abuse or neglect is disclosed in your interactions with a player, you will need to follow local and / or national protocols / legislation around safeguarding and reporting.